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6 NEW SUSTAINABILITY FRAMING This chapter focuses on new efforts for sustainability and ways to include health considerations in major decisions and policies affecting society. The speakers approach the topic from a U.S. perspective, highlighting the need for integrated solutions to complex problems that cross economic, social, and environmental domains. Emphasis is placed on decision makers to consider the broader landscape and potential health impacts when adopting policies and programs. A summary of the presentations follows in which the speakers outline strategies for new sustainability opportunities. THE HEALTH LENS OF SUSTAINABILITY Richard J. Jackson, M.D., M.P.H. Professor and Chair, Department of Environmental Health Sciences School of Public Health University of California, Los Angeles Richard J. Jackson explained that the physical environment we design as a society can impact human health. For example, where buildings and homes are built may determine how far people drive and how much air pollution is created, and how roads are built and where forests are removed may increase the extent of water pollution. Jackson stated that scientists and decision makers tend to focus on the end of the disease model, looking at particulates and water pollutants, and tend to overlook the upstream drivers of disease. What this means in practice, he said, is that issues related to atmospheric carbon dioxide (CO2) levels, global warming, economic difficulties, obesity, diabetes, and other diseases are 105

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106 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY each addressed as separate problems without recognizing that solutions must be proposed to solve them collectively. Jackson stated that society is on a collision course where the economic, social (including health), and environmental factors are likely to result in a “perfect storm” that will affect our nation’s well-being. He noted that the country continues in a severe recession that has disproportionately impacted the poor, young adults, and African Americans. At the same time, the health of children in the United States is impacted, where over the last three decades, overweight and obesity rates have increased threefold among 12–19-year-olds and fourfold among 6–11-year-olds (Babey et al., 2009). The rate of obesity among adults in the United States has doubled over this same period. But more strikingly, the overall prevalence of diabetes in U.S. adults has doubled in just 10 years and the estimated cost of diagnosed diabetes in the United States increased to $245 billion in 2012, a 41 percent increase over 2007 estimates (American Diabetes Association, 2013). And with the current trends in care, U.S. health care expenditures are expected to reach almost 20 percent of GDP in the next 6 years (Keehan et al., 2008). Jackson emphasized that no country can likely survive once it starts spending over approximately 25 percent of its income on a non-wealth- generating activity. Turning to the environmental factors, Jackson noted that current CO2 levels are now dramatically higher in the earth’s atmosphere than they have been in more than 650,000 years (Schrag, 2011). He stated that much of the global carbon emissions are produced through transportation and electricity generation mechanisms. Jackson pointed out that sustained elevated levels of CO2 in the atmosphere will require many generations to dissipate, leading to global warming and serious loss of land and fresh water aquifers due to increased ocean levels. For many decision makers, he said, the magnitude of these effects is difficult to comprehend. Jackson noted that political leaders often dismiss health issues, particularly environmental issues, until the leaders themselves are affected either personally or politically (such as when insecticide levels in the Sacramento River killed a significant number of fish or when New Orleans was confronted with the environmental health effects of Hurricane Katrina). Jackson described that the crisis the world faces today is as much of a moral and ethical dilemma as it is a technical, environmental, social, and economic problem. The Environmental Protection Agency’s (EPA’s)

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NEW SUSTAINABILITY FRAMING 107 draft regulation on greenhouse gas loading received criticism from the energy sector suggesting that it may negatively impact economic growth and job creation within the United States (API, 2011). Jackson noted that while scientists have been quick to discuss the technical issues around these regulations, they have been slow to provide insight on the moral and ethical issues. He stated that there is a moral obligation among scientists to discuss the social and cultural failings that are affecting the population (naming greed as an example of a moral failing embedded in our society). Jackson emphasized that as a guardian or caretaker, the Earth should be able to provide adequate food, water, clothing, and shelter for the next generations, but this will require more serious thought and action than what is seen in society today. 21st-Century Solutions Jackson stated that we need to embrace 21st-century solutions with integrated strategies and plans to address multiple interlinked problems. He noted that with the exception of immunization efforts, overall population health is marginally affected by medical care decisions; health is determined more by decisions made about agriculture, transportation, housing, economic, and education policies than it is by medical decisions. Jackson emphasized that this reality argues that decision makers need to embrace a “health in all policies” approach, which would be the first feature of a 21st-century solution. He stated that scattered throughout the country are examples where co-benefits can be gained through interconnected solutions to pressing issues. Looking at personal health and transit, a study conducted on the light rail system in Charlotte, North Carolina, concluded that the likelihood that passengers would meet their physical activity standards was statistically higher than that of nonpassengers (MacDonald et al., 2010). On average, these passengers weighed 5 to 6 pounds less over the course of 2 years and were 81 percent less likely to become obese over time (MacDonald et al., 2010). Jackson noted that these individuals did not even realize they were exercising since this health behavior was simply built into their lives. Jackson stated that a second feature of a 21st-century solution is inclusion of the “hardware and software,” in that both social and physical components are needed to achieve these goals. A simple example, he said, can be found in providing safe routes for children to travel to school, where safe paths with crosswalks and social networks (the

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108 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY parents, parent-teacher associations, and school organizations) are utilized to promote health and safety. Jackson asserted that all too often the physical environment is emphasized with minimal consideration for the social environment. Jackson noted that top-down and bottom-up leadership (from ethical, personal, social, and economic perspectives) is a third feature of a 21st- century solution. For example, prior to the 1993 National Research Council (NRC) report Pesticides in the Diets of Infants and Children, the general viewpoint was that people were not being significantly exposed to pesticides and regulations were not needed (NRC, 1993). One outcome from this report was the Food Quality Protection Act of 19961 that gave the EPA broad authority to study pesticides and to study the effects on infants. Jackson pointed out that this top-down leadership subsequently led to significant reductions in the residues of pesticides in food, as well as fewer applications and longer preharvest intervals.2 With bottom-up leadership, New York City has transitioned from possessing virtually no bicycle lanes to approximately 900 miles of them (New York City Department of City Planning, 2013). Jackson stated that not only does biking dramatically reduce carbon emissions, it also promotes health and well-being and is less expensive than driving. These examples show how top-down and bottom-up leadership works and how solutions need to be driven from both ends. Jackson explained that a fourth feature of a 21st-century solution includes examining the positive and negative health impacts that may arise from government policies and decisions. For example, the U.S. interstate highway system was one of the largest capital investments in the history of the world, yet population health was never considered during its development. In 1969, the National Environment Policy Act (NEPA)3 was enacted and was one of the first laws that established a broad national framework for protecting the environment. NEPA assures that all branches of government give proper consideration to the 1 Food Quality Protection Act of 1996, Public Law 104-170, 104th Cong., August 3, 1996. 2 The preharvest interval is a function of a pesticide’s use pattern and of the amount of pesticide residues allowed on the crop at harvest. See http://onvegetables.files.wordpress.com/2010/07/factsheet_respect_phirei_ english_2007.pdf (accessed April 24, 2013). 3 National Policy Environmental Act of 1969 (NEPA), Public Law 91-190, 91st Cong., January 1, 1970.

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NEW SUSTAINABILITY FRAMING 109 environment prior to undertaking any major federal action that could significantly affect the environment. Jackson proposed that health impact assessments (HIAs) are necessary to ensure that health is taken into account in major decisions affecting society. An HIA is “a combination of procedures, methods, and tools by which a policy, program, or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population” (Gothenburg Consensus Paper, 1999). He noted that the goal of a HIA is to focus the attention of decision makers on the health consequences of the projects and policies they are considering to allow for better informed decisions with respect to health. For example, as a result of an HIA, walking and bicycle routes were included in the design of the Cooper River Bridge in Charleston, South Carolina. Once installed, these routes became very popular with tourists and residents alike and provided an opportunity for physical activity. Jackson stated that many people believe that NEPA has required HIAs all along. However, the typical environmental impact statement required by NEPA before a project can begin generally contains only a brief and perfunctory HIA statement indicating that no air or water standards will be violated. Jackson noted that this lack of health consideration is inadequate to deal with the crises facing society today. He added that HIAs must be adopted in a cross-cutting fashion when dealing with global issues such as economics, health, environment, transportation, housing, and education. Overall, Jackson said, HIAs must contain a fair weighing of risks and benefits of a proposed action, and the resulting recommendations should be implemented in a collective manner to solve multiple major societal problems.

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110 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY SUSTAINABILITY AND EXPOSURE: INSIGHTS FROM THE NRC REPORT Bernard D. Goldstein, M.D. Professor Emeritus, Department of Environmental and Occupational Health Graduate School of Public Health University of Pittsburgh Bernard D. Goldstein noted that the origins of the U.S government’s interest in sustainability dates back to the U.S. National Environmental Policy Act of 1969,4 signed by President Richard Nixon, where the federal government recognized the interactions of human activity (i.e., urbanization, industrialization, population growth, and resource exploitation) with the natural environment and the ultimate effect on the welfare of humans. The act affirmed a national policy that “means to create and maintain conditions, under which humans and nature can exist in productive harmony, that permit fulfilling the social, economic, and other requirements of present and future generations.” Reaffirmed in Executive Order 13514, signed by President Barack Obama on October 5, 2009, this act laid out the rationale for the importance of the United States to be economically productive while protecting valuable resources and human health. Goldstein stated that in an effort to incorporate sustainability concepts into their agency’s program and to move toward an integrated systems approach to solve complex environmental challenges, the EPA commissioned a National Research Council (NRC) consensus com- mittee. The Committee on Incorporating Sustainability in the U.S. Environmental Protection Agency had a statement of task to advise the EPA on an operational shift within the agency from a risk assessment/risk management (RA/RM) focus to one of sustainability.5 The committee, comprising 12 experts from an array of disciplines, held a two-day workshop consisting of data-gathering sessions. During these 4 National Policy Environmental Act of 1969 (NEPA), Public Law 91-190, 91st Cong., January 1, 1970. 5 This report was released shortly after Dr. Goldstein’s presentation. The interested reader is directed to the National Academies Press’s website for access to the PDF of the report: http://www.nap.edu/catalog.php?record_ id=13152.

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NEW SUSTAINABILITY FRAMING 111 sessions, Goldstein said, the committee heard from EPA officials, state agencies, industry representatives, universities, and nongovernmental organizations. The resulting report addressed the following key questions (NRC, 2011):  “What should be the operational framework for sustainability for EPA?  How can the EPA decision-making process rooted in the risk assessment/risk management (RA/RM) paradigm be integrated into this new sustainability framework?  What scientific and analytical tools are needed to support the framework?  What expertise is needed to support the framework?” Goldstein suggested that should the EPA adopt the framework prescribed by the committee and reorganize from a RA/RM paradigm to one of sustainability, it will likely be a slow transition. For example, the Clean Air Act of 19706 and the Clean Water Act of 1972,7 both of which involved risk-based approaches, were passed years prior to the EPA’s alignment with the RA/RM paradigm. Approximately a decade after the seminal 1983 NRC report Risk Assessment in the Federal Government (also known as the Red Book) (NRC, 1983) was released, which defined the RA/RM paradigm, the EPA reorganized itself to follow the report recommendations. Goldstein noted that an adoption of the sustainability framework by the EPA will require more international collaboration than previously required for the implementation of the risk paradigms. When the National Academy of Sciences developed the current RA/RM paradigm in 1983, the United States defined hazard as being intrinsic and risk as requiring exposure. Other countries were defining the terms the opposite way, he stated. Goldstein outlined that as the United States had the most experience and was leading the field, the global community adopted and adjusted their models of risk assessment to align with the U.S. framework. Currently, he said, other countries are producing far more and potentially superior work regarding sustainability frameworks than 6 Clean Air Act of 1970, 84 Stat. 1676, Public Law 91-604, 91st Cong., December 31, 1970. 7 Federal Water Pollution Control Act Amendments of 1972 (Clean Water Act), 83 Stat. 852, Public Law 92-500, 92nd Cong., October 18, 1972.

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112 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY the United States is producing. Thus, adopting a sustainability paradigm will require far more global cooperation with international partners. Goldstein proposed that implementing a sustainability framework within the EPA would be a two-step process. He stated that the Sustainability and the U.S. EPA report (NRC, 2011) focuses on defining the framework, and this framework will then be scaled up under the broader NRC study that began in September 2011: Sustainability Linkages in the Federal Government. This stage-two report will focus on the details for how the framework may best be implemented. Similar to the adaptation of the risk assessment paradigm, measuring the efficacy of implementing the sustainability paradigm is critical, stated Goldstein. The 2011 report contains the framework for approaching sustainability, but the tools that need to be developed have to comply with the legal framework for the EPA as determined by Congress. He noted that these tools will need to be progressively realized and developed, including trade-off, economic environmental justice, and life- cycle analyses. He added that risk assessment and risk management are seen as continuing and as fitting well under the sustainability framework. The shift to sustainability aims to empower the EPA to go beyond decreasing the risk level by considering the social and economic inputs. Goldstein emphasized that the goal is to maximize benefits while reducing risk, and implementing the framework will require additional expertise and multisectoral collaboration. DISCUSSION A discussion followed the presentations from Jackson and Goldstein and the remarks are summarized in this section. John Balbus commented on the compelling way Jackson framed the obesity epidemic in the United States, and asked the presenter to describe the nature of the evidence that supports interventions in the built environment to address obesity. As an example, Jackson stated, of the additional 25 pounds on the average adult body, approximately 5 to 6 of those pounds seem to be well-linked to non-walkable environments. A second major contributor to this weight gain is the availability of food in our communities, where high-calorie and high-fat options are more accessible and less costly than healthier food options. Similar to evidence that supports tobacco

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NEW SUSTAINABILITY FRAMING 113 interventions, noted Jackson, tax policies for sugar-sweetened beverages, environmental policies to create physical areas where people can exercise, and social policies to reframe the problem through advertising could all work to address obesity. William Sullivan highlighted a challenge in assessing the effectiveness of interventions within the built environment given the inability to randomly assign people to live in treatment or control conditions. Sullivan emphasized the need to carry out smart studies to raise the visibility of these interventions and produce results that can control for self-selection bias and other methodological limitations. Hernando Perez commented on the need to consider the social environment in addition to the built environment in these settings. Perez stated that even the ideal built environment would not be utilized by a community lacking social supports or public safety structures. Nsedu Witherspoon noted the importance of including mental health in discussions around communities and obesity as well. Looking at the health sustainability implications, Wilfried Kreisel stated that obesity could be addressed similarly to how we approach climate change and its impacts on health, given that both problems involve national, international, moral, and ethical constraints. Jackson noted how the research around public health and urban planning is changing, with joint programs being initiated throughout the United States to develop integrated solutions that cross domains. Jackson emphasized the need to start talking more about this research and potential solutions. Jamie Bartram went back to the idea of study design and noted that in environmental health there is a very complex matrix to determine intervention impact, which is intrinsically linked to the randomized controlled trial (RCT) approach. However, he said, the RCTs are a small part of a large, complex question. Bartram suggested that it may be useful to guide how evidence from different disciplines and sectors can be joined to give a practical view to these complex questions and interventions (which may parallel the HIA way of thinking). Kirk Smith agreed with the need for more intervention research and noted that scalability should be included in the framework given that it can be difficult to effectively study an intervention that can be scaled up through existing societal mechanisms, such as legislation or taxes. Smith also noted that many people are interested in the dose response of interventions with regard to scalability, to assess the cost required to achieve an effect that makes sense on a larger scale.

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114 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY Shifting to communications strategies, Paul Wilkinson noted the need to utilize positive messages when presenting information to promote a sustainability agenda since people in general respond better to positive ideas. Wilkinson stated that sustainable interventions are often things that can dramatically improve the quality of life for people, children, families, communities, and so forth, which should be emphasized rather than what you must not do or other negative framing techniques. Witherspoon noted the need to assist with and communicate on existing programs that may be addressing the complex problems around obesity, poverty, and crime in order to raise the visibility of positive outcomes. Ciro Sumaya then presented the idea of partnerships, and the benefit that could be realized by reaching out to champions in the field or stakeholder and advocate groups that could help make a movement around these particular sustainability and environmental health issues. Similar to what was mentioned above, Sumaya noted the importance of articulating the successes or resiliencies that may exist within communities that are already working on these issues and the need to make good use of these experiences through modeling or other interventional research activities. Goldstein stated that this type of research could be placed into the sustainability framework that he described earlier to assess the co- benefits that may result from various interventions. He pointed out that this framework could incorporate social, economic, and environmental benefits from an intervention which also decreases obesity within the United States. Goldstein concluded by noting that the major intervention put forward to address obesity will likely be medical if the quality of evidence to support environmental health interventions does not improve. REFERENCES American Diabetes Association. 2013. Economic costs of diabetes in the U.S. in 2012. Diabetes Care 36(4):1033-1046. API (American Petroleum Institute). 2011. API to White House: If you’re serious about jobs, stop this unnecessary ozone review. http://www.api.org/news-and-media/news/newsitems/2011/jul-2011/api-to- white-house (accessed April 24, 2013).

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NEW SUSTAINABILITY FRAMING 115 Babey, S. H., M. Jones, H. Yu, and H. Goldstein. 2009. Bubbling over: Soda consumption and its link to obesity in California. Policy Brief UCLA Center for Health Policy Research (PB2009-5):1-8. Gothenburg Consensus Paper. 1999. Health impact assessment: Main concepts and suggested approach. Brussels: European Centre for Health Policy. Keehan, S., A. Sisko, C. Truffer, S. Smith, C. Cowan, J. Poisal, M. K. Clemens, and National Health Expenditure Accounts Projections Team. 2008. Health spending projections through 2017: The baby-boom generation is coming to Medicare. Health Affairs 27(2):w145-w155. MacDonald, J., R. J. Stokes, D. A. Cohen, A. Kofner, and G. K. Ridgeway. 2010. The effect of light rail transit on body mass index and physical activity. American Journal of Preventive Medicine 39(2):105-112. New York City Department of City Planning. 2013. Bicycle network develop- ment. http://www.nyc.gov/html/dcp/html/bike/home.shtml (Accessed April 24, 2013). NRC (National Research Council). 1983. Risk assessment in the federal government: Managing the process. Washington, DC: National Academy Press. NRC. 1993. Pesticides in the diets of infants and children. Washington, DC: National Academy Press. NRC. 2011. Sustainability and the U.S. EPA. Washington, DC. The National Academies Press. Schrag, D. P. 2011. Energy, climate, and human health. PowerPoint present- ation at the Institute of Medicine workshop on Ensuring and Strengthening Public Health Linkages in a Sustainable World, Washington, DC.

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